1. Periscopic Spine Surgery Technology Developments in Minimally Invasive Procedures Kevin Cleary, PhD Imaging Science and Information Systems (ISIS) Center Computer Assisted Interventions Laboratory Department of Radiology Georgetown University Medical Center Washington, DC October 2002

2. Periscopic Spine SurgeryGeorgetown UniversitySlide 2 Overview of Presentation Background ISIS Center / mobile CT Medical robotics –Review –Spinal nerve blocks at Georgetown Image-guided surgery (magnetic localization) Summary

3. Periscopic Spine SurgeryGeorgetown UniversitySlide 3 Background

4. Periscopic Spine SurgeryGeorgetown UniversitySlide 4 Georgetown University Located in Washington, DC Large, private university –Medical school –Law school –International studies Ranked in top 25 hospitals in U.S. No engineering school

5. Periscopic Spine SurgeryGeorgetown UniversitySlide 5 Radiology Equipment 2 MRI –Research MRI: 7T 3 fixed CT –Siemens SOMATOM Volume Zoom (CT fluoro) Mobile CT scanner 2 angiography labs (+1 soon) 3 fluoroscopy units –Siemens MultiStar –Siemens NeuroStar biplane system 3D Virtuoso software (accelerator board) 3 general radiology rooms 7 ultrasound machines 5 portable C-arms (3 angio capable) 1 PET scanner

6. Periscopic Spine SurgeryGeorgetown UniversitySlide 6 ISIS Center Imaging Science and Information Systems (ISIS) Part of Radiology Department Collaborations with many departments 30 people (faculty, staff, and support) Completely externally funded Director: Seong Ki Mun, PhD

7. Periscopic Spine SurgeryGeorgetown UniversitySlide 7 ISIS Center Research Areas Image processing –Digital mammography –Computer aided diagnosis Telemedicine Chronic disease: web-based monitoring Computer aided surgery (image-guided surgery, medical robotics, etc.)

8. Periscopic Spine SurgeryGeorgetown UniversitySlide 8 Mobile CT Scanner Operational April 1998 117 cases to date (Feb 2000) –Interventional Radiology Spinal interventions Drainage procedures –Operating Room Complex Spinal Tumor Resections Head and Neck surgery Craniotomies

9. Periscopic Spine SurgeryGeorgetown UniversitySlide 9 Workstation Mobile CT Components Gantry and Table

10. Periscopic Spine SurgeryGeorgetown UniversitySlide 10 Interventional Suite Layout

11. Periscopic Spine SurgeryGeorgetown UniversitySlide 11 Volume Rendered Image (Cement in Green)

12. Periscopic Spine SurgeryGeorgetown UniversitySlide 12 Volume Rendered Image (Cement Green)

13. Periscopic Spine SurgeryGeorgetown UniversitySlide 13 Tumor Resection in OR with mobile CT for visualization Spine tumor resection & stabilization

14. Periscopic Spine SurgeryGeorgetown UniversitySlide 14 Medical Robotics Review

15. Periscopic Spine SurgeryGeorgetown UniversitySlide 15 Medical Robotics Tremendous potential for improving the precision and capability of physicians to perform minimally invasive procedures At the beginning of the application of robotics to medicine Many questions remain as to effectiveness, safety, and cost

16. Periscopic Spine SurgeryGeorgetown UniversitySlide 16 Medical Robotics (continued) Several commercial companies selling medical robots –Total installed base is extremely small –Market will most likely continue to grow slowly While factory robotics grew rapidly during the 1970s and 1980s, medical robotics has not yet reached a critical mass Believed the benefits of medical robotics will become increasingly clear and this will lead to a continued rise in their use in medicine.

17. Periscopic Spine SurgeryGeorgetown UniversitySlide 17 Clinical Applications Neurosurgery Orthopaedic Urology Maxillofacial Opthamology Radiosurgery Cardiology

18. Periscopic Spine SurgeryGeorgetown UniversitySlide 18 Neurosurgery First recorded medical use of a robot –Kwoh 1985 Simple positioning device to orient a brain biopsy needle Robot held a needle guide and surgeon inserted needle Not continued due to safety concerns

19. Periscopic Spine SurgeryGeorgetown UniversitySlide 19 Neurosurgery: Minerva

20. Periscopic Spine SurgeryGeorgetown UniversitySlide 20 MR Com- patible Robot Courtesy, Nobuhiko Hata, Ron Kikinis SPL, Boston

21. Periscopic Spine SurgeryGeorgetown UniversitySlide 21 Ortho- paedics : Robo- Doc Courtesy Integrated Surgical Systems

22. Periscopic Spine SurgeryGeorgetown UniversitySlide 22 Maxillo -facial Tim Lueth, Charite, Berlin

23. Periscopic Spine SurgeryGeorgetown UniversitySlide 23 Radiosurgery Accuray (Stanford) Cranial, spine, lung, pancreas, tracking of respiratory motion

24. Periscopic Spine SurgeryGeorgetown UniversitySlide 24 Russ Taylor, Johns Hopkins University Optha- ma- logy

25. Periscopic Spine SurgeryGeorgetown UniversitySlide 25 Cardiology: Intuitive Surgical Telesurgery System Source: (Fox news archive) (www.intusurg.com)

26. Periscopic Spine SurgeryGeorgetown UniversitySlide 26 Intuitive Surgical Components

27. Periscopic Spine SurgeryGeorgetown UniversitySlide 27 Intuitive Surgical Console

28. Periscopic Spine SurgeryGeorgetown UniversitySlide 28 Questions Is there a large base of installed medical robots? Are there niche markets? Will robots replace surgeons? Is there a robot in your future?

29. Periscopic Spine SurgeryGeorgetown UniversitySlide 29 Spine Robotics at Georgetown Robot Mobile CT gantry

30. Robot designed and constructed by Dan Stoianovici, PhD, Hopkins URobotics Laboratory Georgetown University

31. Periscopic Spine SurgeryGeorgetown UniversitySlide 31 Robot in Interventional Suite

32. Periscopic Spine SurgeryGeorgetown UniversitySlide 32 Robotically Assisted Nerve and Facet Blocks: Purpose of Clinical Study To demonstrate that a physician controlled robotic needle driver is equivalent in safety and effectiveness to the standard manual technique for needle placement in nerve and facet blocks in the perispinal region

33. Periscopic Spine SurgeryGeorgetown UniversitySlide 33 Nerve and Facet Blocks Typically done by interventional neuroradiologists For both diagnosis and therapy Requires accurately placing a thin needle (usually 22 gauge) under fluoroscopic guidance Typical procedure time: 30 minutes High volume procedure Not technically demanding

34. Periscopic Spine SurgeryGeorgetown UniversitySlide 34 Cadaver Study Purpose: evaluate feasibility of using robot to place needle for perispinal nerve and facet blocks Date: 1 September 2001

35. Periscopic Spine SurgeryGeorgetown UniversitySlide 35 Materials and Methods Small metal BB targets placed in lumbar spine at 3 levels 6 nerve block targets and 6 facet block targets Physician attempts to drive needle to target using joystick to control robot Accuracy of placement evaluated on x- ray images (goal: within 3 mm)

36. Periscopic Spine SurgeryGeorgetown UniversitySlide 36 BBs Used as Targets

37. Periscopic Spine SurgeryGeorgetown UniversitySlide 37 Placement of Target BB’s

38. Periscopic Spine SurgeryGeorgetown UniversitySlide 38 Scout CT Showing BB Targets

39. Periscopic Spine SurgeryGeorgetown UniversitySlide 39 Physician Operating Robot

40. Periscopic Spine SurgeryGeorgetown UniversitySlide 40 Robot and Needle Holder

41. Periscopic Spine SurgeryGeorgetown UniversitySlide 41 Needle Holder Close-up

42. Periscopic Spine SurgeryGeorgetown UniversitySlide 42 Anterior/Posterior Fluoro Image BB

43. Periscopic Spine SurgeryGeorgetown UniversitySlide 43 Lateral Fluoroscopic Image of BB BB Needle

44. Periscopic Spine SurgeryGeorgetown UniversitySlide 44 Axial CT Image of BB & Needle Tip BB Needle

45. Periscopic Spine SurgeryGeorgetown UniversitySlide 45 Results & Conclusion All 12 needles were placed within 3 mm of the target BB A joystick controlled robotic needle driver can be used by the interventionalist to accurately place needles in the nerve and facet regions Clinical studies are required to investigate the advantages and disadvantages of this system for interventional needle procedures

46. Periscopic Spine SurgeryGeorgetown UniversitySlide 46 FDA Approval Received 20 patients in initial study 100 patients next March 2002 IRB approvals –Georgetown –Army

47. Periscopic Spine SurgeryGeorgetown UniversitySlide 47 FDA IDE clinical trial study outline

48. Periscopic Spine SurgeryGeorgetown UniversitySlide 48 Benefits of Robotic Guidance Improved path planning More precision control of needle trajectory Allows operator to advance needle and view trajectory in real-time without exposure to x-ray field

49. Periscopic Spine SurgeryGeorgetown UniversitySlide 49 And now to the video...

50. Periscopic Spine SurgeryGeorgetown UniversitySlide 50 Localization (non-line-of-sight tracking)

51. Periscopic Spine SurgeryGeorgetown UniversitySlide 51 Liver Respiratory Motion Simulator Goal: demonstrate magnetic tracking technology for interventional procedures Initial target: liver Collaboration with Northern Digital & Traxtal Technologies AURORA™ magnetic tracking system Left to right: control unit, sensor interface device, and magnetic field generator (Courtesy of Northern Digital Inc.)

52. AURORA Tracking System 1. Tetrahedron shaped field generator 2. The position sensor is made of a induction coil with a diameter of 0.9 mm

53. Periscopic Spine SurgeryGeorgetown UniversitySlide 53 Liver Respiratory Motion Simulator Components

54. Demonstration: Berlin June 2001

55. Periscopic Spine SurgeryGeorgetown UniversitySlide 55 Demonstration Baltimore April 2002

56. Periscopic Spine SurgeryGeorgetown UniversitySlide 56 Clinical Scenario Pre-procedure CT Registration step –Fiducials in CT space –Fiducials in magnetic space Provide image overlay and respiratory tracking during procedure Confirming image upon completion

57. Periscopic Spine SurgeryGeorgetown UniversitySlide 57 Interventional Suite Testing

58. Periscopic Spine SurgeryGeorgetown UniversitySlide 58 Respiratory Motion Simulator GUI Patent Pending: All Rights Reserved

59. Periscopic Spine SurgeryGeorgetown UniversitySlide 59 Results: Biopsy Experiments

60. Periscopic Spine SurgeryGeorgetown UniversitySlide 60 Results: Vessel Puncture

61. Periscopic Spine SurgeryGeorgetown UniversitySlide 61 Cadaver Study: Introducing Catheter

62. Periscopic Spine SurgeryGeorgetown UniversitySlide 62 Cadaver Study: Field Generator

63. Periscopic Spine SurgeryGeorgetown UniversitySlide 63 Cadaver Study: Liver Needle Placement

64. Periscopic Spine SurgeryGeorgetown UniversitySlide 64 Liver Simulator Demo Video

65. Periscopic Spine SurgeryGeorgetown UniversitySlide 65 Summary Focus on precision minimally invasive procedures Clinical relevance is key Collaboration between engineer and physician Prospects for future are bright

66. Periscopic Spine SurgeryGeorgetown UniversitySlide 66 Acknowledgements Clinicians –Vance Watson, MD, Radiology –Elliot Levy, MD, Radiology –Filip Banovac, MD, Radiology –Matthew Freedman, MD, Radiology / ISIS Center Scientists / Researchers –David Lindisch, RT, Radiology / ISIS Center –Daigo Tanaka, MA, ISIS Center –Seong K. Mun, PhD, Radiology / ISIS Center Students –Sheng Xu, Johns Hopkins ERC CISST Collaborators –Dan Stoianovici, PhD, Johns Hopkins Urology / ERC CISST –Russell Taylor, PhD, Johns Hopkins ERC CISST –Gabor Fichtinger, PhD, Johns Hopkins ERC CISST –Charles Nguyen, PhD, Catholic University Funding –US Army Medical Research and Materiel Command